UmarMedicalCentre - NHS Blackburn with Darwen CCG

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Inadequate –––

Are services safe? Inadequate –––

Are services effective? Inadequate –––

Are services caring? Requires improvement –––

Are services responsive to people’s needs? Inadequate –––

Are services well-led? Inadequate –––

UmarUmar MedicMedicalal CentrCentreeQuality Report

3 Lime StreetBlackburnLancashireBB1 7EPTel: 01254 287070Website: www.umarmedicalcentre.nhs.uk

Date of inspection visit: 7 March 2018Date of publication: 14/05/2018

1 Umar Medical Centre Quality Report 14/05/2018

Contents

PageKey findings of this inspectionLetter from the Chief Inspector of General Practice 2

The six population groups and what we found 4

Detailed findings from this inspectionOur inspection team 5

Background to Umar Medical Centre 5

Detailed findings 7

Action we have told the provider to take 21

Letter from the Chief Inspector of General PracticeThis practice is rated as Inadequate overall. (Previousinspection July 2016 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

As part of our inspection process, we also look at thequality of care for specific population groups. Thepopulation groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired andstudents – Inadequate

People whose circumstances may make them vulnerable– Inadequate

People experiencing poor mental health (includingpeople with dementia) - Inadequate

We carried out an announced comprehensive inspectionat Umar Medical Centre on 7 March 2018 in response toconcerns raised by members of the public.

At this inspection we found:

• The practice was negotiating a period of transitionwith recent changes to the GP partnership and anewly appointed practice manager. The practice hadalso experienced a turbulent time over recentmonths with staff absence.

• There was some confusion amongst staff aroundroles, responsibilities and the staffing structure. Wefound staff morale was low with limited evidence of ateam ethos.

• The practice lacked clear systems to manage riskand mitigate against the repeat of safety incidents.When incidents did happen, we found exampleswhere the practice had not learned from them orimproved its processes.

• There was limited evidence of clinical audit or qualityimprovement to demonstrate the effectiveness andappropriateness of the care provided.

• Staff delivered care and treatment according toevidence-based guidelines.

Key findings


• The practice demonstrated an awareness of thepatient population it served and took pride in beingintegrated into the local community. The GPsdelivered healthcare awareness sessions at the localmosque and schools.

• We found significant gaps in governancearrangements. There were gaps in practice policiesand procedures to govern key activities.

• The practice was unable to evidence that aninfection prevention and control audit had beencompleted.

• There was a lack of managerial oversight of trainingand staff training needs. Appraisals for staff had notbeen completed regularly.

• Information flow within the practice was largelyinformal. The practice lacked a meeting structure toformally document the dissemination of anychanges to staff.

• Patients rated the practice lower than others formany aspects of care, although patients told us staffinvolved and treated them with compassion,kindness, dignity and respect.

• Patients found the appointment system confusing touse and reported that they could not always accesscare when they needed it.

• The practice lacked a systematic approach tomanaging and responding to patient complaints.

• There was confusion and dysfunction in how thepractice managed incoming post.

The areas where the provider must make improvementsas they are in breach of regulations are:

• Ensure care and treatment is provided in a safe wayto patients.

• Ensure there is an effective system for identifying ,receiving ,recording, handling and responding tocomplaints by patients and other persons in relationto the carrying on of the regulated activity.

• Establish effective systems and processes to ensuregood governance in accordance with thefundamental standards of care.

The areas where the provider should makeimprovements are:

• Work should continue to identify and supportpatients who are also carers.

• Undertake activity to proactively promote uptake ofbreast and bowel cancer screening.

I am placing this service in special measures. Servicesplaced in special measures will be inspected again withinsix months. If insufficient improvements have been madesuch that there remains a rating of inadequate for anypopulation group, key question or overall, we will takeaction in line with our enforcement procedures to beginthe process of preventing the provider from operating theservice. This will lead to cancelling their registration or tovarying the terms of their registration within six months ifthey do not improve.

The service will be kept under review and if needed couldbe escalated to urgent enforcement action. Wherenecessary, another inspection will be conducted within afurther six months, and if there is not enoughimprovement we will move to close the service byadopting our proposal to remove this location or cancelthe provider’s registration.

Special measures will give people who use the service thereassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older people Inadequate –––

People with long term conditions Inadequate –––

Families, children and young people Inadequate –––

Working age people (including those recently retired andstudents)

Inadequate –––

People whose circumstances may make them vulnerable Inadequate –––

People experiencing poor mental health (including peoplewith dementia)


Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC lead inspector.The team included a GP specialist adviser and a CQCinspection manager.

Background to Umar MedicalCentreUmar Medical Centre is a GP practice registered with CQCunder a partnership of Drs Anwar and Sarah Alam. A thirdGP partner, Dr Mohammed Alam, had joined the practice inApril 2017, but at the time of our inspection had not beenadded to the CQC provider registration. It is a singlelocation registered at the main site (3 Lime Street,Blackburn, BB1 7EP) with a branch surgery situated inDarwen (42 Railway Road, Darwen, BB3 2RJ). Thisinspection visited the main site only. The main site issituated in a residential area close to the centre of thetown. There is limited on-street parking.

The practice delivers primary medical services to a list sizeof approximately 8100 patients under a personal medicalservices (PMS) contract with NHS England, and is part ofthe NHS Blackburn with Darwen Clinical CommissioningGroup.

The average life expectancy of the practice population is inline with the local and slightly lower than national averages(76 years for males and 81 years for females, compared to79 and 83 years nationally).

The practice delivers services to a patient cohort consistingof 69% black and ethnic minority (BME) groups. Thepractice caters for a lower proportion of patients over the

age of 65 years (7%) and 75 years (3%) compared to local(14% and 6% respectively) and national averages (17% and8% respectively). The practice has a higher proportion ofyounger patients under the age of 18 years (33%, comparedto 25% locally and 21% nationally). The practice also catersfor a lower percentage of patients who experience a longstanding health condition (43%, compared to the local andnational averages of 54%).

Information published by Public Health England rates thelevel of deprivation within the practice population group astwo on a scale of one to ten. Level one represents thehighest levels of deprivation and level ten the lowest.

The practice is staffed by three GP partners (two males andone female) and a further three salaried GPs (two malesand one female). In addition the practice employs anadvanced nurse practitioner and two practice nurses. At thetime of our inspection the practice was in the process ofrecruiting a health care assistant. Clinical staff aresupported by a practice manager who had been in postsince January 2018 and a team of nine administrative andreception staff.

The main surgery is open between 8am and 6.30pmMonday, Wednesday and Friday, 8am and 8pm Tuesday,and 8am and 8.30pm on a Thursday. The branch surgeryopens between 8am and 12.30 and then between 2.30pmand 6pm each Monday, Wednesday and Friday and from8am until 12.30 and 1.30pm until 4.30pm each Tuesday andThursday. Surgeries are offered throughout the time thepractice is open. Extended hours appointments areavailable on Tuesday and Thursday evenings. In addition,the practice’s patients can access extended hoursappointments until 8pm on weekday evenings and onweekends at four other local practices. Theseappointments can be booked through the practice’sreceptionists and are offered by the local GP federation.

UmarUmar MedicMedicalal CentrCentreeDetailed findings


Outside normal surgery hours, patients are advised tocontact the out of hours service by dialling 111, offeredlocally by the provider East Lancashire Medical Services.

The practice had previously been inspected on 27 July2016, when a full comprehensive inspection wascompleted. Following this inspection the practice was ratedgood overall.

Detailed findings


Our findingsWe rated the practice, and all of the populationgroups, as inadequate for providing safe services.

The practice was rated as inadequate for providing safeservices because there was a dysfunctional system formanaging incoming correspondence to the practice,learning from significant events was not implementedeffectively and there were gaps in the management of risk.

Safety systems and processes

The practice had some systems to keep patients safe andsafeguarded from abuse, although we noted these systemswere not always comprehensive.

• The practice had a suite of safety policies includingadult and child safeguarding policies which weremarked as being regularly reviewed. However, not allstaff we spoke with were aware of their location, and wefound sections of the safeguarding children policy whichhad not been made practice specific.

• There was a system to maintain a risk register ofvulnerable patients.

• The practice worked with other agencies to supportpatients and protect them from neglect and abuse. Stafftook steps to protect patients from abuse, neglect,harassment, discrimination and breaches of theirdignity and respect.

• Most staff had received up-to-date safeguarding andsafety training appropriate to their role. However, thepractice was not able to evidence that the GPsafeguarding lead had completed safeguarding childrentraining to the required level three. The practicemanager was also aware that some staff were overduerefresher training in safeguarding, as per the practice’spolicy, which stated training should be completed everythree years. Staff knew how to identify and reportconcerns, and the GPs were able to describe exampleswhere they had liaised with social services to ensurevulnerable patients received appropriate support. Staffwho acted as chaperones were trained for the role andhad received a DBS check. (DBS checks identify whethera person has a criminal record or is on an official list ofpeople barred from working in roles where they mayhave contact with children or adults who may bevulnerable).

• We saw the practice had carried out staff checks,including checks of professional registration whererelevant, on recruitment of permanent members of staff.Disclosure and Barring Service (DBS) checks wereundertaken where required. However, we did note thatthe practice had no documented evidence of conduct inprevious employment for a locum GP working in thepractice on the day of inspection, nor evidence ofsafeguarding and basic life support training completed.

• The system to manage infection prevention and control(IPC) was not thorough. We asked to view the mostrecent IPC audit the practice had completed but nosuch audit could be located by practice staff. Thepractice’s IPC policy stated that IPC inspections wouldbe completed at least every two months, but there wasno evidence of this.

• There were systems for safely managing healthcarewaste.

• The practice ensured that facilities and equipment weresafe and that equipment was maintained according tomanufacturers’ instructions.

Risks to patients

There were not adequate systems to assess, monitor andmanage risks to patient safety.

• There were arrangements for planning and monitoringthe number and mix of staff needed. However, there wasa lack of clarity around both clinical and non-clinicalstaff roles and responsibilities, with several staff tellingus they were unaware of roles carried out by theircolleagues, in particular in relation to the managementof incoming correspondence to the practice. We weretherefore not assured there was an effective approachto managing staff absences and for responding toepidemics, sickness, holidays and busy periods. We sawa lack of appropriate knowledge and skill mix amongststaff to provide flexibility and cover.

• There was an induction system for new staff tailored totheir role. However, staff informed us this was notalways sufficient to provide adequate training in orderto become competent and autonomous in the role.

• The practice was equipped to deal with medicalemergencies and staff were suitably trained inemergency procedures.

Are services safe?



• Staff understood their responsibilities to manageemergencies on the premises and to recognise those inneed of urgent medical attention. Clinicians knew howto identify and manage patients with severe infectionsincluding sepsis.

Information to deliver safe care and treatment

We were not assured staff always had the information theyneeded to deliver safe care and treatment to patients. Thepractice did not have thorough systems for sharinginformation with staff and other agencies to enable themto deliver safe care and treatment. For example, at the timeof our inspection the practice did not have a documentedprocedure for the management of incomingcorrespondence. Staff we spoke with were unclear as tohow this was done, with contradictory descriptions beingoffered. A number of staff informed us that incoming mailwas triaged by non-clinicians, with some filed straight intothe patient record without a clinician having sight of it andno audit of this process.

During the inspection we found a backlog of 149 patientletters stored electronically which were showing on thepractice’s electronic system as not being actioned. We sawexamples of these which dated back to June 2017.However, we reviewed a sample of these and corroboratedin the patient’s records that any necessary action had beencompleted. The practice provided assurance following theinspection that these letters logged on the system hadbeen cleared, with all appropriate actions completed asnecessary.

Safe and appropriate use of medicines

The practice had reliable systems for appropriate and safehandling of medicines.

• The systems for managing and storing medicines,including vaccines, medical gases, and emergencymedicines and equipment minimised risks. The practicekept prescription stationery securely and monitored itsuse.

• Staff prescribed, administered or supplied medicines topatients and gave advice on medicines in line with legalrequirements and current national guidance. Thepractice had reviewed its antibiotic prescribing andtaken some action to support good antimicrobial

stewardship in line with local and national guidance.The practice was working with the clinicalcommissioning group’s medicines management team tofurther improve this.

• Patients’ health was monitored to ensure medicineswere being used safely and followed up onappropriately. The practice involved patients in reviewsof their medicines.

• Prescribing data for the practice for 01/07/2016 to 30/06/2017 showed that the average daily quantity ofHypnotics prescribed per Specific Therapeutic groupwas better than local and in line with national averages;1.05, compared to 1.24 locally and 0.9 nationally. (Thisdata is used nationally to analyse practice prescribingand Hypnotics are drugs primarily used to induce sleep.)

• Similar data for the prescribing of antibacterialprescription items showed that practice prescribing wasslightly above local and national levels; 1.22 comparedto 1.11 locally and 0.98 nationally.

• The percentage of antibiotic items prescribed by thepractice that were Co-Amoxiclav, Cephalosporins orQuinolones (antibiotics which work against a widerange of disease-causing bacteria) was 6.8%, comparedto the local average of 7% and national average of 8.9%.

Track record on safety

The practice needed to improve its systems around safety.

There were comprehensive risk assessments in relation tosafety issues, however they had not been reviewed in atimely manner. For example, fire risk assessments had beencompleted for both the main and branch sites, datedAugust 2010 and June 2010 respectively. These documentsstated they should be reviewed when any changes weremade to the premises, or at least every three years.However, during the visit the practice could notdemonstrate that a review of the risk assessments hadbeen undertaken. The practice was unable to evidence thatthe recommended mitigating actions identified in the riskassessments were routinely undertaken. For example, thepractice was unable to evidence that monthly testing ofemergency lighting was carried out in line with therecommendation of the fire risk assessments. Thedocuments also stipulated that annual tests of the firealarm should be completed, but the practice could onlyevidence this was last carried out on 24 June 2016.

Are services safe?



After the inspection, the practice was able to provide anadditional fire risk assessment dated March 2014 for themain site. This included an action plan. However thisaction plan had not been updated to document any actioncompleted as a result.

A legionella risk assessment was documented for the mainsite, dated April 2014 (legionella is a term for a particularbacterium which can contaminate water systems inbuildings). This risk assessment stated it should bereviewed after two years. This review had not beenundertaken. A legionella risk assessment at the branch sitehad been completed in May 2016. Both legionella riskassessments recommended regular flushing from wateroutlets at specified temperatures. The practice managerconfirmed to us that this had not been done.

Lessons learned and improvements made

The practice did not have an adequate system in place tolearn and make improvements when things went wrong.

• Systems in place for recording and acting on significantevents and incidents were not adequate. Processes inplace for reviewing and investigating when things wentwrong presented risk that incidents could be repeated.The practice provided us with a summary of eightsignificant events logged and investigated in theprevious 12 months. However, during the inspection wefound evidence of a further incident which had not beenwritten up and logged as such, involving a staff memberworking outside their competencies. While the practicehad taken action, it had not been logged and treated asa significant event analysis (SEA), as the practice hadbeen advised to do by their medical defence insuranceprovider. There was no evidence of shared learningamongst the wider staff group.

• We noted a trend of four SEAs logged between June andJuly 2017 all relating to the management of incomingcorrespondence to the practice and associated

medication errors. We viewed the documentationrelating to two of these SEAs, which indicated that at thetime a healthcare assistant (HCA) employed at thepractice had responsibility for triaging incomingcorrespondence and deciding which letters the GPsneeded sight of. The documentation of the SEAsindicated actions which needed implementing in orderto mitigate against the incidents being repeated. Theseactions included staff attending workflow optimisationtraining and undertaking a letter-reading audit tofacilitate clinical oversight by the GPs of themanagement of letters in the practice. We found noevidence that any such audit had been completed.While the HCA and practice manager had attendedworkflow optimisation training, neither were employedby the practice any longer. At the time of our inspectionthe practice did not have a documented procedure forthe management of incoming correspondence.

• There was little evidence of the outcomes of incidentinvestigations being shared with the wider staff in orderto maximise learning. Staff we spoke with were unableto give us examples of recent SEAs and minutes frommeetings where we were told they were discussed werenot available for the inspection team to view during thevisit. After the inspection the practice provided copies oftwo meeting agendas dated July 2017 and informed usthe SEA documentation from a number of previousincidents constituted the minutes of these meetings.

• We asked to view documentation relating to an SEAlogged in March 2017 relating to a cancer diagnosis,however documentation could not be located bypractice staff during the inspection.

• The system for receiving and acting on safety alerts wasnot comprehensive. The practice did not maintain anaudit trail of any required actions taken on receipt ofsuch alerts, and we found two examples of relevantalerts that the GPs had not had sight of.

Are services safe?



Our findingsWe rated the practice and all of the population groupsas inadequate for providing effective services.

The practice was rated as inadequate for providingeffective services because there was limited evidence ofquality improvement work including clinical audit, a lack ofmanagerial oversight of unmet training needs amongstnon-clinical staff and the potential for poorly coordinatedcare as a result of poor information flow within the practice.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date withcurrent evidence-based practice. Clinicians attended thetwice yearly ‘hot topics’ learning events arranged by theclinical commissioning group (CCG). We saw that cliniciansassessed needs and delivered care and treatment in linewith current legislation, standards and guidance supportedby clear clinical pathways and protocols.

• Patients’ immediate and ongoing needs were fullyassessed. This included their clinical needs and theirmental and physical wellbeing.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• Staff advised patients what to do if their condition gotworse and where to seek further help and support.

We reviewed evidence of practice performance againstresults from the national Quality and Outcomes Framework(QOF) for 2016/17 and looked at how the practice providedcare and treatment for patients (QOF is a system intendedto improve the quality of general practice and reward goodpractice.)

Older people:

• The practice had not used an appropriate tool toidentify patients aged 65 and over who were living withmoderate or severe frailty. Some patients living withfrailty had been identified by the local palliative careservice and the practice was aware of these patients.

• The practice liaised regularly with the lead doctor fromthe local hospice to ensure the needs of patientsnearing the end of life were met appropriately.

• The practice had identified four patients on its palliativecare register.

• Staff had appropriate knowledge of treating olderpeople including their psychological, mental andcommunication needs.

People with long-term conditions:

• Patients with long-term conditions had a structuredannual review to check their health and medicinesneeds were being met. For patients with the mostcomplex needs, the GP worked with other health andcare professionals to deliver a coordinated package ofcare.

• Staff who were responsible for reviews of patients withlong term conditions had received specific training.

• The practice lacked a systematic approach to followingup patients who had received treatment in hospital orthrough out of hours services.

• Blood measurements for diabetic patients (HbA1c of 64mmol/mol or less in the preceding 12 months) showedthat 86% of patients had well controlled blood sugarlevels compared with the CCG and national averages of80%. However, the practice exception reporting rate forthis indicator was 22%, compared to the CCG average of13% and national average of 12%. (Exception reportingis the removal of patients from QOF calculations where,for example, the patients decline or do not respond toinvitations to attend a review of their condition or whena medicine is not appropriate).

• The percentage of diabetic patients for whom the lastblood pressure reading was 140/80mmHg or less was90%, compared to the CCG average of 79% and nationalaverage of 78%. However, the practice exceptionreporting rate for this indicator was 22%, compared tothe CCG and national averages of 9%.

• The practice employed a GP with special interest indiabetes for one session per week to cater for the needsof more complex diabetic patients.

Families, children and young people:

• Childhood immunisations were carried out in line withthe national childhood vaccination programme. Uptakerates for the vaccines given had achieved the targeted90% in three of the four indicators for vaccinations givento children under the age of two years. The percentageof one year old children with the full course ofrecommended vaccines in 2016/17 was 86%.

Are services effective?(for example, treatment is effective)



• The practice hosted clinics run by the midwife twice perweek.

• The GPs met with the health visitor on a monthly basisto discuss patients and ensure care was coordinated.

Working age people (including those recently retired andstudents):

• The practice’s uptake for cervical screening was 49%,which was significantly below the CCG average of 69%and national average of 72%. The practice was aware ofthis low uptake and had recently increased nursingcapacity in an effort to address it. The practice informedus that the local GP federation had recently startedoffering targeted weekend clinics where cervicalscreening was available for the practice’s patients. In thefirst two months since they commenced, these clinicshad completed 81 smear tests.

• The practices’ uptake for breast and bowel cancerscreening was lower than the national average. Forexample, 28% of patients aged between 60 and 69 hadbeen screened for bowel cancer within six months ofinvitation, compared to the CCG average of 51% andnational average of 54%. The percentage of femalesaged between 50 and 70 screened for breast cancerwithin six months of invitation was 47%, compared tothe CCG average of 56% and national average of 62%.

• Patients had access to appropriate health assessmentsand checks including NHS checks for patients aged40-74. There was appropriate follow-up on the outcomeof health assessments and checks where abnormalitiesor risk factors were identified.

People whose circumstances make them vulnerable:

• End of life care was delivered in a coordinated waywhich took into account the needs of those whosecircumstances may make them vulnerable. We notedthe practice had identified four patients on its palliativecare register. The GPs felt this number was low due tocoding issues on the electronic patient record system.The practice worked closely with the doctor from thelocal hospice to ensure the needs of patients nearingthe end of life were best met.

• The practice held a register of patients living invulnerable circumstances including those with alearning disability.

People experiencing poor mental health (including peoplewith dementia):

• 78% of patients diagnosed with dementia had their carereviewed in a face to face meeting in the previous 12months, compared to the CCG and national averages of84%.

• 93% of patients diagnosed with schizophrenia, bipolaraffective disorder and other psychoses had acomprehensive, agreed care plan documented in theprevious 12 months, compared to the CCG average of93% and national average of 90%.

• The practice specifically considered the physical healthneeds of patients with poor mental health and thoseliving with dementia. For example 94% of patientsexperiencing poor mental health had receiveddiscussion and advice about alcohol consumption,compared to the CCG average of 94% and nationalaverage of 91%.

• The practice did not document care plans for patientsdiagnosed with dementia.

• Patients with complex mental health needs were offeredan annual review and were signposted to the local‘well-being’ service which offered counselling support.

Monitoring care and treatment

The most recent published QOF results achieved by thepractice were 98.5% of the total number of points availablecompared with the CCG average of 98.3% and nationalaverage of 96.5%. The overall exception reporting rate was18.7% compared with a CCG average of 11.1% and nationalaverage of 9.6%. In particular, the practice’s exceptionreporting for diabetes indicators was higher than local andnational averages. We saw that the practice was utilisingexception reporting appropriately in the sample of recordswe reviewed. The GPs informed us they expected thecurrent year’s QOF performance to be lower due to thestaffing issues the practice had experienced over theprevious 12 months.

The practice did not have a comprehensive programme ofquality improvement activity and did not share evidencewith us demonstrating it routinely reviewed theeffectiveness and appropriateness of the care provided.Limited evidence was available of clinical audit, wherechanges made were revisited and evaluated foreffectiveness. The practice shared a summary documentindicating three audits had been commenced. One was




dated as 2015/16 (prior to our previous inspection)examining the diagnosis of uncomplicated urinary tractinfections (UTI). This summary indicated the practice wasmostly diagnosing UTI in line with Public Health Englandguidance, and that the guidance was circulated toclinicians in an effort to prompt further improvement in thisarea. A joint injection audit summary dated 2015/16 and2016/17 suggested there were no patients sufferingpost-operative complications. The summary documentalso referenced an undated audit commenced examiningthe recording of blood pressure checks for patientsreceiving hormone replacement therapy. The write upindicated that nine patients had been identified as needingto be called in to see the healthcare assistant in order tohave their blood pressure checked. The GPs informed usthese patients were recalled to the practice, but this hadnot been documented as part of the audit documentationshared with us.

After the inspection the practice provided a further morerecent audit cycle following up on the diagnosis of UTIwhich indicated compliance with guidance had improvedfrom 80% to 85%.

Effective staffing

Clinical staff had the skills, knowledge and experience tocarry out their roles. For example, staff whose role includedimmunisation and taking samples for the cervicalscreening programme had received specific training andcould demonstrate how they stayed up to date. However,we spoke with non-clinical staff who felt there were unmettraining needs amongst this group, with the high turnoverof reception and administration staff contributing to a lackof confidence in autonomous working.

• The practice could not demonstrate it had an up to dateunderstanding of the learning needs of staff. There wasa lack of managerial oversight of training; for examplethe practice manager informed us the practice’s trainingmatrix was not fully up to date.

• We saw some evidence the practice provided staff withongoing support. For example, the newly appointednurse practitioner had met with one of the GPs toensure appropriate coaching, mentoring and oversightof their clinical decision making including non-medicalprescribing was in place. However, the practice lacked asystematic approach to ensuring non-clinical staff hadaccess to appraisals as a means to monitor

performance, development and training needs.Evidence provided by the practice indicated non-clinicalstaff had not received an appraisal since summer 2016and staff we spoke with confirmed it had been sometime since they were last formally appraised.

• There was a clear approach for managing staff whentheir performance was poor or variable. We sawevidence the practice liaised with its medical defenceunion to ensure appropriate action was taken. However,we saw an example where this advice had not beenfollowed fully, in that an incident had not been loggedfully as a significant event.

Coordinating care and treatment

Staff worked together and with other health and social careprofessionals to deliver effective care and treatment.However, the lack of clarity around the management ofcorrespondence from secondary care presented the risk ofinefficient and disjointed information flow within thepractice with regards to the treatment needs of patients.

• We saw records that showed that all appropriate staff,including those in different teams, services andorganisations, were involved in assessing, planning anddelivering care and treatment. The practice heldsix-weekly multi-disciplinary team meetings to discusspatients with more complex needs. However, theminutes we viewed of these meetings did not indicatewhich professionals had attended. Following theinspection, the practice sourced an attendance list forthe most recent of these meetings from the localityteam co-ordinator who arranged them, and shared thiswith the inspection team.

• The practice ensured that end of life care was deliveredin a coordinated way which took into account the needsof different patients, including those who may bevulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients tolive healthier lives.

• The practice identified patients who may be in need ofextra support and directed them to relevant services.This included patients in the last 12 months of their livesand patients at risk of developing a long-term condition.




• The percentage of new cancer cases who were referredunder the two-week-wait referral pathway was abovelocal and national averages (75% compared to 50%locally and 52% nationally).

• Staff encouraged and supported patients to be involvedin monitoring and managing their health.

• Staff discussed changes to care or treatment withpatients and their carers as necessary.

• The practice supported national priorities and initiativesto improve the population’s health, for example, stopsmoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in linewith legislation and guidance.

• Clinicians understood the requirements of legislationand guidance when considering consent and decisionmaking.

• Clinicians supported patients to make decisions. Whereappropriate, they assessed and recorded a patient’smental capacity to make a decision.




Our findingsWe rated the practice, and all of the populationgroups, as requires improvement for caring.

The practice was rated as requires improvement forproviding caring services due to poor patient satisfactionand the lack of a coordinated approach to identifying andsupporting patients identified as carers.

Kindness, respect and compassion

Staff treated patients with kindness, respect andcompassion.

• Staff understood patients’ personal, cultural, social andreligious needs.

• Reception staff knew that if patients wanted to discusssensitive issues or appeared distressed they could offerthem a private space to discuss their needs.

• Of the 17 patient Care Quality Commission commentcards we received, 14 were positive about the serviceexperienced. Comments indicated many patients feltlistened to, with two of the cards naming specificclinicians to praise the care and treatment they offered.Three comment cards we received raised someconcerns about the practice. These concerns related toaccess to the service, the timeliness of treatment andthe attitude of staff.

Results from the July 2017 annual national GP patientsurvey showed patients mostly felt they were treated withcompassion, dignity and respect. A total of 388 surveyswere sent out and 103 were returned. This represented aresponse rate of 27% and was about 1% of the practicepopulation. The practice was below average for itssatisfaction scores on consultations with GPs and nurses.For example:

• 82% of patients who responded said the GP was good atlistening to them compared with the clinicalcommissioning group (CCG) average of 91% and thenational average of 89%.

• 95% of patients who responded said they hadconfidence and trust in the last GP they saw; CCG - 95%;national average - 96%.

• 78% of patients who responded said the last GP theyspoke to was good at treating them with care andconcern; CCG– 87%; national average - 86%.

• 79% of patients who responded said the nurse wasgood at listening to them; CCG - 91%; national average -91%.

• 75% of patients who responded said the last nurse theyspoke to was good at treating them with care andconcern; CCG - 91%; national average - 91%.

• 49% of patients who responded said they wouldrecommend the practice to someone who had justmoved to the local area; CCG – 81%; national average –79%.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about theircare:

• Many staff were multi-lingual and interpretation serviceswere available for patients who did not have English asa first language.

• Staff communicated with patients in a way that theycould understand.

• Staff helped patients and their carers find furtherinformation and access community and advocacyservices. They helped them ask questions about theircare and treatment.

Practice staff experienced difficulty during the inspectioninterrogating the practice’s electronic record system to tellus how many patients it had identified as carers. We weretold by the GPs that the practice did not maintain a carers’register, with the suggestion that they were not fully codedon the electronic record system. However, five days afterthe inspection the practice supplied evidencedemonstrating that 58 patients had been identified ascarers (0.7% of the practice list). The GPs informed us thepractice did not have a nominated staff member to act ascarers’ champion, and were unaware of any specificsupport available for carers locally. We did noteinformation leaflets for carers in the patient waiting area.

The GPs told us that if families had experiencedbereavement, their usual GP contacted them by telephone.This call was followed by a patient consultation at a flexibletime and location to meet the family’s needs as necessary.

Are services caring?

Requires improvement –––


Results from the national GP patient survey showedpatients mostly responded positively to questions abouttheir involvement in planning and making decisions abouttheir care and treatment. However, results were lower thanlocal and national averages:

• 76% of patients who responded said the last GP theysaw was good at explaining tests and treatmentscompared with the CCG average of 88% and the nationalaverage of 86%.

• 69% of patients who responded said the last GP theysaw was good at involving them in decisions about theircare; CCG - 84%; national average - 82%.

• 74% of patients who responded said the last nurse theysaw was good at explaining tests and treatments; CCG -90%; national average - 90%.

• 71% of patients who responded said the last nurse theysaw was good at involving them in decisions about theircare; CCG - 87%; national average - 85%.

Privacy and dignity

The practice respected patients’ privacy and dignity.

• Staff recognised the importance of patients’ dignity andrespect.

• The practice was aware that conversations withreceptionists could be overheard by patients in thewaiting room; the practice planned to redesign thereception area to address this in the near future.

Are services caring?

Requires improvement –––


Our findingsWe rated the practice, and all of the populationgroups, as inadequate for providing responsiveservices.

The practice was rated as inadequate for providingresponsive services because patients found it difficult toaccess the service and the practice did not have acomprehensive system in place for managing patientcomplaints.

Responding to and meeting people’s needs

The practice told us it aimed to organise and deliverservices to meet patients’ needs. It took account of patientneeds and preferences.

• The practice understood the needs of its population andtailored services in response to those needs. Forexample, extended opening hours, online services suchas repeat prescription requests and advanced bookingof appointments.

• We saw that the practice was integrated into the localcommunity; one of the GPs had run health promotionand awareness sessions at the local mosque andschools.

• The facilities and premises were appropriate for theservices delivered.

• The practice made reasonable adjustments whenpatients found it hard to access services, for example byoffering home visits where necessary.

• Care and treatment for patients with multiple long-termconditions and patients approaching the end of life wascoordinated with other services.

Older people:

• All patients had a named GP who supported them inwhatever setting they lived, whether it was at home or ina care home or supported living scheme.

• The practice was responsive to the needs of olderpatients, and offered home visits and urgentappointments for those with enhanced needs.

People with long-term conditions:

• Patients with a long-term condition received an annualreview to check their health and medicines needs werebeing appropriately met.

• The practice held regular meetings other professionalsto discuss and manage the needs of patients withcomplex medical issues.

Families, children and young people:

• All parents or guardians calling with concerns about achild under the age of 18 were offered a same dayappointment when necessary.

• The GPs told us children who arrived late for theirappointment were always seen by the clinician.

• The practice was aware of the tendency of the localpopulation to bring multiple family members to a singleappointment, and so had built in ‘blocks’ to theappointment system to accommodate this, savingmultiple trips to the practice for the family and ensuringall patients’ needs were met.

Working age people (including those recently retired andstudents):

• The needs of this population group had been identifiedand the practice had adjusted the services it offered toensure these were accessible, flexible and offeredcontinuity of care. For example, extended opening hoursand online facilities.

• Telephone consultations were available whichsupported patients who were unable to attend thepractice during normal working hours.

People whose circumstances make them vulnerable:

• The practice held a register of patients living invulnerable circumstances including those with alearning disability.

• Patients with complex needs were offered longerappointments.

People experiencing poor mental health (including peoplewith dementia):

• Staff interviewed had a good understanding of how tosupport patients with mental health needs and thosepatients living with dementia.

• The practice held a register of patients who haddementia and of those who had complex mental healthneeds.

Timely access to care and treatment

Are services responsive to people’s needs?(for example, to feedback?)



Some patients expressed frustration and felt they were notable to access care and treatment from the practice withinan acceptable timescale for their needs. Three of thepatient comment cards returned and one patient we spokewith on the telephone told us the appointment system wasconfusing. We were given examples by patients where theywere told different information regarding appointmentavailability and the booking process by different membersof practice staff. They also told us the practice could be verydifficult to contact by telephone.

The practice was aware of the high proportion ofappointments where patients failed to attend(approximately five per day of the 30 urgent on the dayappointments offered) and was planning to shortlyintroduce measures to address this. For example, ademonstration of a text messaging reminder service hadbeen arranged for two weeks after our inspection, with aview to the practice commencing its use.

Patients with the most urgent needs had their care andtreatment prioritised. The GPs informed us that theyensured children were seen the same day, and wouldalways be seen if they arrived late for their appointment.

Results from the July 2017 annual national GP patientsurvey showed that patients’ satisfaction with how theycould access care and treatment was lower than local andnational averages. This was supported by observations onthe day of inspection and completed comment cards.

• 63% of patients who responded were satisfied with thepractice’s opening hours compared with the clinicalcommissioning group (CCG) average of 83% and thenational average of 80%.

• 35% of patients who responded said they could getthrough easily to the practice by phone; CCG – 71%;national average - 71%.

• 46% of patients who responded said that the last timethey wanted to speak to a GP or nurse they were able toget an appointment; CCG - 76%; national average - 76%.

• 70% of patients who responded said their lastappointment was convenient; CCG - 81%; nationalaverage - 81%.

• 40% of patients who responded described theirexperience of making an appointment as good; CCG -76%; national average - 73%.

• 29% of patients who responded said they don’tnormally have to wait too long to be seen; CCG - 61%;national average - 58%.

The practice were aware of these low results, and felt therecruitment of additional clinical staff and resultingincreased clinical capacity would improve patient access.

Listening and learning from concerns and complaints

The practice’s system for managing patient complaints wasnot adequate. The practice had logged six complaintsreceived in the previous 12 months. We saw informationabout how to make a complaint or raise concerns wasavailable. Staff treated patients who made complaintscompassionately. The practice’s complaint policy andprocedures were in line with recognised guidance.

We reviewed two complaints and we were unable to verifythey had been satisfactorily handled due to gaps indocumentation the practice held regarding the complaints.For example we asked to view documentation relating toone complaint logged on the practice’s summary sheetdated July 2017. We saw the practice’s written response tothe complaint dated 6 October 2017. However, the practicewas unable to locate the original complaint letter from thepatient. The second complaint we viewed was dated 11August 2017. The practice had responded in writing on 21August 2017. We noted the practice’s response did notsignpost the patient to the Parliamentary Health ServiceOmbudsman should they wish to escalate their complaintif they were unhappy with the practice’s response. Wenoted the patient had lodged a follow up complaint withthe practice on 5 September 2017 as they were unhappywith the practice’s original response. The practice could notevidence during the inspection that it had responded tothis second letter. After the inspection, the practice wasable to locate the letters relating to the complaints.

Are services responsive to people’s needs?(for example, to feedback?)



Our findingsWe rated the practice and all of the population groupsas inadequate for providing a well-led service.

The practice was rated as inadequate for well-led becausethe governance structure did not provide adequatesystems and processes to ensure safe and effective care.

Leadership capacity and capability

The practice leadership structure was in a period oftransition, with new GP partners and practice managementsince our previous visit. At the time of our inspection thepractice found it difficult to evidence that leaders had thecapacity and skills to deliver high-quality, sustainable care.We noted that the practice leadership was working within anumber of constraints, including for example those causedby staff absence and turnover. We saw that the newlyappointed practice manager was experienced and hadbeen recruited from a credible professional backgroundwithin primary care. However, they had not yet been in postsufficient time to implement and embed required changes.

Leaders demonstrated some knowledge about issues andpriorities relating to the quality and future of services.There was some understanding of the challenges and anaction plan had been formulated to work towardsaddressing them. This action plan addressed topics such aspatient satisfaction and the low uptake of cervicalscreening.

Vision and strategy

The practice was developing a vision and strategy toimprove the quality and sustainability of care.

• There was a clear vision and set of values. The practicewas committed to providing patient centred care withinthe community.

• The practice lacked a formally documented long termbusiness plan to support the vision and strategy.

• Staff were aware of the patient centred values of thepractice and of their role in achieving them.

Culture

The practice was working to embed a culture ofhigh-quality sustainable care.

• An ethos of team work was not embedded in practice.Some staff disclosed to us that staff morale was low.

• We saw some examples where leaders and managersacted on behaviour and performance inconsistent withthe vision and values.

• We saw examples where openness and transparencyhad not been fully demonstrated when responding toincidents and complaints.

• Staff we spoke with told us they were aware of how toraise concerns. However, staff were less clear about howthey would receive feedback regarding how any suchconcerns had been addressed.

• Processes for providing all staff with the developmentthey needed, including appraisal and careerdevelopment conversations were not thorough. Thepractice was unable to demonstrate that non-clinicalstaff had received appraisals in the last year.

• Staff were supported to meet the requirements ofprofessional revalidation where necessary.

• Clinical staff, including nurses, were given someprotected time for professional development andevaluation of their clinical work, although this was notalways sufficient.

• There had been a high turnover of staff in recentmonths.

• The practice actively promoted equality and diversity.The training matrix indicated staff had received equalityand diversity training.

Governance arrangements

There was a lack of clarity around responsibilities, rolesand systems of accountability to support good governanceand management.

• Structures, processes and systems to support goodgovernance and management were not set out,understood or effective. The governance andmanagement of partnerships, joint workingarrangements and shared services promoted interactiveand co-ordinated person-centred care.

• Staff were not clear on their roles and accountabilitiesincluding in respect of key practice processes related toinformation flow within the organisation and infectionprevention and control.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)



• Practice leaders had not established proper policies,procedures and activities to ensure safety and had notassured themselves that key activities undertaken wereoperating as intended. For example, the practice did nothave a documented protocol for the management ofincoming correspondence at the time of inspection, andan audit of this activity had not been completed despitethe outcome of a significant event stipulating that thisshould be done.

• We saw examples of practice policies, dated as reviewedin February / March 2018, which contained inaccurate oroutdated information. For example, the chaperonepolicy referred to the PCT (the Primary Care Trust whichhad ceased to exist in 2013).

• The practice lacked a clear meeting structure as meansof formalising dissemination of information to the staffteam. Staff confirmed to us they had not attended staffor team meetings for some time. The lead receptionistat the branch site worked only at that premises so hadlimited contact with the rest of the staff team.

Managing risks, issues and performance

The practice lacked clear and effective processes formanaging risks, issues and performance.

• The process to identify, understand, monitor andaddress current and future risks including risks topatient safety was not comprehensive.

• The practice had processes to manage current andfuture performance. Performance of employed clinicalstaff could be demonstrated through audit of theirconsultations, prescribing and referral decisions.However, there were unmet training needs amongstnon-clinical staff. For example, on the day of inspectionstaff had considerable difficulty interrogating theelectronic patient record system in order to runsearches.

• Practice leaders lacked appropriate oversight ofnational and local safety alerts, incidents, andcomplaints.

• Clinical audit was not embedded into practice. Thepractice was unable to evidence that changes to clinicalprocesses as a result of audit had a positive impact onquality of care and outcomes for patients, as they hadnot been routinely revisited for evaluation.

• The practice had plans in place and had trained staff formajor incidents.

Appropriate and accurate information

The practice could not always clearly demonstrate how itacted on appropriate and accurate information.

• We were not assured that information from secondarycare providers (for example from hospitalappointments) was always seen and acted on in atimely manner; the practice had failed to implement aneffective system.

• We did not see evidence during the inspection thatquality and sustainability were discussed in relevantmeetings where all staff had sufficient access toinformation. We were told by the practice manager andGPs that such information was discussed at meetingsheld at the GPs’ houses, involving only the partners andwere not minuted. However, after the inspection thepractice provided minutes of a business meeting heldon 9 January 2018.

• Quality and operational information was not effectivelyused to ensure and improve performance.

• The information the practice told us it used to monitorperformance and the delivery of quality care wasaccurate and useful. There were plans to address someof the identified weaknesses.

• The practice used information technology systems tomonitor and improve the quality of care, although somestaff were not proficient in the use of the electronicpatient record system.

• The practice submitted data or notifications to externalorganisations as required.

Engagement with patients, the public, staff andexternal partners

The practice was attempting to involve patients, the public,staff and external partners to support high-qualitysustainable services.

• The practice was aware of the below average patientfeedback from the GP patient survey, and hoped therecent increase in clinical capacity at the practice wouldimprove patient experience.




• The practice manager informed us the patientparticipation group had lapsed and was no longeractive, but they were working to reinstate it.

• The service was transparent, collaborative and openwith stakeholders about performance. We saw how thepractice had engaged with a recent quality visit from theCCG.

Continuous improvement and innovation

There was some evidence of systems and processes forlearning and continuous improvement.

• The practice was engaging with a local initiative aroundcare navigation in order to better inform patients of thebest avenues to access care and treatment required.

• The practice had been successful in a bid for funding fora GP assistant’s post which would create a single pointof contact within the practice team for patients withlonger term health needs.

However, the practice needed to make better use ofinternal and external reviews of incidents and complaints.Learning was not shared effectively to make improvements.




Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 16 HSCA (RA) Regulations 2014 Receiving andacting on complaints

How the regulation was not being met:

The registered person had failed to establish and operateeffectively an accessible system for identifying, receiving,recording, handling and responding to complaints byservice users and other persons in relation to thecarrying on of the regulated activity. For example, wefound examples where either the original complaintletter from a patient, or response letter from the practicewere not available for us to view.

This was in breach of regulation 16(2) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.

Regulation

This section is primarily information for the provider

Requirement notices


Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.



Surgical procedures


Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment


The registered persons had not done all that wasreasonably practicable to mitigate risks to the health andsafety of service users receiving care and treatment. Inparticular, documented mitigating actions followinganalyses of incidents had not been completed. Theseactions related to the safe management of incomingcorrespondence to the practice. At the time of our visitthere were 149 letters flagged on the patient recordsystem as not having been actioned.




Surgical procedures


Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance


There were insufficient systems or processes thatenabled the registered person to assess, monitor andmitigate the risks relating to the health, safety andwelfare of service users and others who may be at risk.For example, there was no documented audit trail ofactions completed on receipt of patient safety alerts.Risk assessments, such as for fire and legionella, wereout of date and recommended mitigating activities hadnot been completed. The practice was unable toevidence that an infection prevention and control audithad been completed. The practice lacked thorough

Regulation

Regulation


Enforcement actions


processes to effectively disseminate learning followingincidents. The practice could not evidence the GPsafeguarding lead had completed required training inthis area.

There were insufficient systems or processes thatensured the registered person had maintained securelysuch records as are necessary to be kept in relation topersons employed in the carrying on of the regulatedactivity or activities. In particular we saw nodocumentation of evidence of conduct in previousemployment for a locum GP working in the practiceduring the inspection.

There were insufficient systems or processes thatenabled the registered person to seek and act onfeedback from relevant persons and other persons onthe services provided in the carrying on of the regulatedactivity, for the purposes of continually evaluating andimproving such services. In particular we found manystaff had not received an appraisal for almost two years.



Enforcement actions


UmarMedicalCentre - NHS Blackburn with Darwen CCG

Documents

Transcript of UmarMedicalCentre - NHS Blackburn with Darwen CCG